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Original Article

VOL. 13 | NO. 3 | ISSUE 51 | JULY-SEPT. 2015

Nepalese Esthetic Dental (NED) Proportion in Nepalese


Population

Rokaya D,1 Kitisubkanchana J,2 Wonglamsam A,3 Santiwong P,4 Srithavaj T,3 Humagain M1

ABSTRACT
Background
1

Department of Dentistry
Kathmandu University School of Medical Sciences,
Dhulikhel, Kavre, Nepal.

Lots of studies on maxillary anterior teeth proportions have been studied in different
populations in various countries, but no studies have been conducted in Nepal on the
esthetic maxillary anterior teeth proportions.

Department of Oral and Maxillofacial Radiology


Department of Prosthodontics
4
Department of Orthodontics
Mahidol University,
6 Yothi Street, Rajathevee,

Objective

2
3

Bangkok 10400, Thailand.

Corresponding Author
Jira Kitisubkanchana
Department of Oral and Maxillofacial Radiology
Faculty of Dentistry, Mahidol University,
6 Yothi Street, Rajathevee,
Bangkok 10400, Thailand.
E-mail: yjira@hotmail.com

Citation
Rokaya D, Kitisubkanchana J, Wonglamsam A,
Santiwong P, Srithavaj T, Humagain M. Nepalese
Esthetic Dental (NED) Proportion in Nepalese
Population. Kathmandu Univ Med J 2015;51(3):
249-54.

The study was done to investigate the maxillary anterior teeth proportions in a
Nepalese population. Teeth proportions in the total population were compared with
golden proportion (GP) and golden standard (GS).
Method
A total of 150 Nepalese subjects were divided in three facial types; broad, average and
narrow group. Maxillary anterior teeth were measured from dental casts using digital
calipers. The perceived width ratios of lateral to central incisor (LI/CI) and canine to
lateral incisor (CN/LI), ratios of mean central incisor length to 2 central incisor widths
(CIL/2CIW), and actual width to length ratios (WLRs) (%) were calculated in each
facial type and compared. Mean LI/CI, CN/LI and CIL/2CIW in total population were
calculated and compared with GP (0.618), and mean WLRs in the total population
were compared with GS (80%). All teeth proportions were compared among three
facial types. One-sample t-test and one-way ANOVA were performed to analyze the
data ( = 0.05).
Result
The LI/CI, CN/LI, CIL/2CIW and WLRs in three facial types showed no significant
difference. The LI/CI, CN/LI and CIL/2CIW in the total population were 66%, 70% and
55% respectively, and were significantly different from GP. The WLRs for CI, LI and CN
in the total population were 90%, 86% and 89% respectively and significantly differed
from GS. These values were considered to constitute the Nepalese Esthetic Dental
(NED) proportion.
Conclusion
No significant difference of maxillary anterior teeth proportions were observed
among three facial types. Teeth proportions in the total population significantly
differed from GP and GS. We propose the NED proportion as a guideline for dental
treatment in the maxillary anterior region in Nepalese populations.

KEY WORDS
Anterior tooth, esthetics, golden proportion, golden standard, Nepalese population,
teeth proportion.

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KATHMANDU UNIVERSITY MEDICAL JOURNAL

INTRODUCTION
Prosthetic and restorative treatment in anterior teeth
should be performed to maximize the esthetic outcome.
The maxillary anterior teeth size, shape and proportion play
an essential role in accomplishing pleasing dental, facial
esthetics and satisfaction.1,2 Various methods for teeth size
determination for restoring and replacing maxillary anterior
teeth includes previous photographs, facial measurements,
facial types, and ideal teeth proportions including golden
proportion (GP) and golden standard (GS) of teeth.2-11
Human faces can be classified as broad, average and
narrow according to the facial index, which is the ratio
of naso-menton length (NML) and bizygomatic width
(BZW).12,13 Facial type of each patient plays an important
role in prosthetic dentistry in artificial teeth selection.
Ward and Berry mentioned that facial types may help in
teeth selection.14,15 Hence, the shape of face may be used
as a guide for teeth selection in maxillary anterior region.
Another method for teeth size determination is using GP.
The term GP was given by Euclid of Alexandria and it is
equal to 1.618 (the ratio of larger to smaller).16 GP can be
seen in nature and human body.17 In dentistry, it is used in
the anterior teeth esthetics.6,7,10,18 Lombardi first proposed
the application of the GP in dentistry in 1973.18 According
to Leven,6,7 GP can be found in the perceived width ratios
of LI/CI, CN/LI and the ratio of mean central incisor length
to 2 central incisor widths (CIL/2CIW). However, GP was not
seen in the maxillary anterior teeth by many authors.1,10,19-31
In addition, Wolfart et al. mentioned that a golden standard
(GS) of 80% was ideal for the width to length ratio (WLR)
of maxillary central incisor.8 In many studies, GS of 80% in
WLRs of maxillary anterior teeth was not found, instead,
the WLRs of maxillary anterior teeth were found to be 6685%.19-21

METHODS
A total of 150 Nepalese medical students (52 males and
98 females) participated in this cross-sectional study
using the criteria: (1) subject is Nepalese by birth, (2) age
of the participants: 16-35 years, both male and female,
(3) no gross asymmetry of the face, (4) no gingival or
periodontal disease, (5) less than 0.5 mm spacing between
anterior teeth, (6) minimal crowding as defined by the
Little Irregularity Index (LII)32 (1 to 3 mm of the linear
displacement of the anterior tooth at five anterior contact
points), (7) no intruded or extruded anterior teeth, (8) no
anterior open bite, (9) no apparent loss of tooth structure
due to attrition, fracture, or caries and (10) no anterior
restoration. Study protocol and ethics were approved
by the Institutional Review Committee of Kathmandu
University School of Medical Science. All participants were
requested to sign an informed consent document before
participating.
Page 250

Figure 1. Measurement
of naso-menton length
(NML) of the face.

Figure 2. Measurement of
bizygomatic width (BZW) of the
face width.

For each participant, NML and BZW were measured using


digital calipers (Model CD-6, Mitutoyo Co., Kanagawa,
Japan) as shown in Fig. 1, Fig. 2. Then facial index (NMH/
BZW) was calculated in percentage and facial type was
classified as broad, average or narrow. Impressions of
the maxillary arch were taken from each participant with
irreversible hydrocolloid (Jeltrate, Dentsply, PA, USA) using
stock tray (Impression Trays, Dentaurum, Germany) and
dental cast was made with dental stone type IV (Vel-Mix
stone, Kerr Co., CA, USA) manipulated according to the
manufacturer instructions. The perceived width of each
anterior tooth was measured according to the method
described by Al-Marzok et al. Each maxillary cast was
placed on a plain paper,20 mesial and distal border lines
were marked and lines were drawn on the paper (Fig.
3a). Then perceived width was measured as the distances
between these lines using digital calipers (Fig. 3b). The
mean LI/CI, CN/LI and CIL/2CIW in each facial type were
calculated and compared among three types. The mean
LI/CI, CN/LI and CIL/2CIW in total studied population were
compared with GP (0.618). Actual width of each anterior
tooth was measured as the maximum mesio-distal distance
and actual length was measured as the longest distance
from the cervical margin to the incisal edge on the dental
cast (Fig. 3c, Fig. 3d). Mean WLRs of each anterior tooth

Figure 3. Measurement of the perceived widths and actual


lengths of the maxillary anterior teeth. Measuring perceived
teeth widths (a): drawing the mesial and distal lines of each
anterior tooth after placing the cast on a plain paper, and (b)
measuring the perceived widths. Measuring actual teeth
measurements (c): measuring the actual widths, and (d):
measuring the actual length.

Original Article

VOL. 13 | NO. 3 | ISSUE 51 | JULY-SEPT. 2015

was calculated and compared among three facial types.


Mean WLRs in the total studied population were compared
with GS (80%).

were found to be 90.36% for central incisors, 86.01% for


lateral incisors and 88.61% for canines. The mean WLRs of
all teeth significantly differed from GS (80%) (p < 0.001).

All measurements were made by one investigator. Each


measurement was measured three times and the mean
value was calculated. Statistical analyses were conducted
using Statistical PASW Statistics 18.0 (SPSS, Chicago, IL,
USA) with the level of significance () = 0.05. One-way
ANOVA (post-hoc: Gabriel) was used to compare the teeth
proportions among three facial types and one-sample
t-test was used to compare the teeth proportions of the
total studied population with GP and GS. To test the validity
of the present study, one week after the completion of
study, 10% of the total participants (15 participants) were
selected according to their availability. All measurements
were repeated and measurement errors were calculated
using Dalhbergs Formula. Power test was used to calculate
the power of our study. Power test above 80% was
considered to be an appropriate power.

Table 2. Mean LI/CI, CN/LI, CIL/2CIW, WLRs and their multiple


comparisons among three facial types

RESULTS
Different facial types obtained from the participants
comprised 11 broad faces, 35 average faces and 104
narrow faces. The narrow facial type was predominant in
this study.
Table 1. Mean LI/CI, CN/LI, CIL/2CIW and WLRs of maxillary
anterior teeth, and their multiple comparisons with GP and GS
in the total studied Nepalese population
Teeth
proportions

Min

Max

Mean SD

p-value
Comparison
with GP

Comparison
with GS

LI/CI

0.54

0.81

0.66 0.60

<.001

CN/LI

0.53

0.85

0.70 0.06

<.001

CIL/2CIW

0.47

0.54

0.55 0.4

<.001

CI WLRs (%)

77.30

99.33

90.36 5.27

<.001

LI WLRs (%)

68.15

102.37

86.01 7.71

<.001

CN WLRs (%)

70.45

103.83

88.61 7.35

<.001

p-values <0.05, indicates statistically significant differences. Min: Minimum; Max: Maximum; SD: standard deviation; GP: Golden proportion
(0.618); GS: Golden Standard (80%); LI/CI: perceived width ratios of lateral incisor to central incisor; CN/LI: perceived width ratios of canine
to lateral incisor; CIL/2CIW: ratios of mean central incisor length to 2
central incisor widths; CI: central incisor; LI: lateral incisor; CN: canine;
WLRs: width to length ratios.

Table 1 shows the mean LI/CI, CN/LI, CIL/2CIW and WLRs


of maxillary anterior teeth in the total studied Nepalese
population. The mean width ratios were 0.66 for LI/CI and
0.70 for CN/LI. One-sample t-test showed that LI/CI and
CN/LI significantly differed from GP (0.618) (p < 0.001). The
mean CIL/2CIW ratio was 0.55. It showed that CIL/2CIW
significantly differed from GP (p < 0.001).The mean WLRs

Teeth
proportions

Broad
(n=11)

Average
(n=35)

Narrow
(n=104)

Mean
SD

Mean
SD

Mean
SD

LI/CI

0.66
0.06

0.66
0.05

CN/LI

0.70
0.05

CIL/2CIW

p-value
Broad
vs.
Average

Average
vs.
Narrow

Broad
vs.
Narrow

0.67
0.06

1.00

0.93

0.98

0.71
0.05

0.69
0.06

0.88

0.37

0.99

0.55
0.03

0.55
0.04

0.55
0.04

0.98

0.97

0.99

CI WLRs
(%)

90.36
5.76

89.36
5.23

90.29
5.26

0.92

0.72

1.00

LI WLRs (%)

86.01
8.96

85.41
6.65

87.24
7.92

0.99

0.50

0.92

CN WLRs
(%)

88.61
8.16

88.28
8.12

89.14
7.05

0.99

0.90

0.99

N: population in each group; SD: standard deviation; LI/CI: perceived width


ratios of lateral incisor to central incisor; CN/LI: perceived width ratios of
canine to lateral incisor; CIL/2CIW: ratios of mean central incisor length to 2
central incisor widths; CI: central incisor; LI: lateral incisor; CN: canine; WLRs:
width to length ratios.

Table 2 shows the mean LI/CI, CN/LI, CIL/2CIW and WLRs


of three facial types and their multiple comparisons among
three groups. The mean LI/CI in broad, average and narrow
types were 0.66, 0.66 and 0.67, respectively and the mean
CN/LI in broad, average and narrow types were 0.70, 0.71
and 0.69, respectively. The mean CIL/2CIW was 0.55 in
each group. The mean WLRs in broad, average and narrow
facial types were 90.36%, 89.36% and 90.29% for central
incisors; 86.01%, 85.41% and 87.24% for lateral incisors
and 88.61%, 88.28% and 89.14% for canines, respectively.
No significant difference was revealed for LI/CI, CN/LI,
CIL/2CIW and WLRs among the three facial types. In this
study, Dalhbergs formula showed the error ranged from
0.12 to 0.67, within an acceptable range. The power of the
test was 98%, implying that the sample size of 150 was
adequate for this study.

DISCUSSION
The facial measurements used for the selection of maxillary
anterior teeth include bizygomatic width, interpupillary
distance, intercanthal distance, mouth width and nose
width.2-5 However, Zlatari et al. suggested that the use of
facial measurements for artificial denture teeth selection
was generally inaccurate and suggested that the teeth
should be selected according to the patients appearance
maintaining both dental and overall facial esthetics.11
Facial types also play an important role in the selection
of artificial teeth as suggested by some authors.14,15 They
expected that size and shape of anterior teeth in each
facial type might differ. Hence, we aimed to compare the
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KATHMANDU UNIVERSITY MEDICAL JOURNAL


teeth proportions among three facial types. We believe
that the Nepalese students who participated in this study
represented the Nepalese population as they were from
different parts of the country. For the classification of facial
types, the facial index was used as in other studies where
direct facial measurement of the face were made.12,13,33,34
The predominant facial type in this study was narrow
followed by average and broad face. This finding was
in agreement with a study conducted among an Iraqi
population (among 100 undergraduate students) showing
that 80% had narrow faces, 16% had average faces and
4% had broad faces.33 A study conducted in a Bangladeshi
population (140 undergraduate dental students) showed
that narrow faces comprised the most common face in
their population (56%) followed by average faces (44%).34
However, in their study, broad face was not found. This all
may indicate that narrow face might be the most common
facial type in the Asian population. In this present study,
teeth proportions (LI/CI, CN/LI, CIL/2CIW and WLRs) among
three facial types showed no significant differences (p >
0.3). Therefore, it showed that facial type might not be an
important factor for the selection of artificial teeth in the
Nepalese population. Maxillary anterior teeth of one size
may be used in any facial type.
Lombardi defined the idea of a repeated ratio,18 implying
that in an optimized dentofacial composition from the
frontal aspect. In addition, he commented that GP has
been proved too strong for dental use. Leven presented
that a relationship exists between the beauty in nature and
mathematics,6,7 and implemented GP in dentistry for the
perceived width ratios of maxillary anterior teeth (LI/CI and
CN/LI). In other words, according to Leven,6,7 the perceived
width of the lateral incisor is 62% of the central incisor and
perceived width of the canine is 62% of the lateral incisor.
However, the results from our study showed that neither
GP was seen for the LI/CI, CN/LI, CIL/2CIW nor GS was
observed for the WLRs of maxillary anterior teeth in the
total population. These results are in accordance with the
other studies in different populations: Turkish, German,
North American, Croatian, Jordanian, Iranian, Indian,
Brazilian, Malaysian, Hungarian, Londoners, Portuguese,
Irish and Korean.8-10,14,18-31 Hence, GP and GS may not be
a proper guideline for anterior teeth selection in esthetic
treatment.
Chu studied the tooth width of the maxillary anterior teeth
among North Americans and suggested the ideal WLRs
of the six maxillary anterior teeth to be 78%.25 Brisman
proposed that the optimal WLRs for maxillary anterior
teeth should be 75%.26 Petricevic et al. studied the WLRs of
maxillary anterior teeth in a Croatian population and found
that WLRs for central incisors,9 lateral incisors and canines
were 90%, 82%, and 84%, respectively. They reported
that these ratios significantly differed from 75% and GS.
Another study by Tsukiyama et al. compared the WLRs
ratios of maxillary anterior teeth among 157 Asians and
142 Caucasians.35 The WLRs ratios of all maxillary anterior
Page 252

teeth significantly differed between Asians and Caucasians.


They concluded that ethnicity influences WLRs for all
maxillary anterior teeth. Maxillary anterior teeth among
Asians appear to be more slender compared with those
among Caucasians. Hence, no universal WLRs for maxillary
anterior teeth was found and WLRs for different population
were found to differ.
Table 3. Formula proposed by Preston10 to calculate maxillary
anterior teeth width and application in Nepalese population
Maxillary anterior teeth width calculation
Anterior
teeth width

Formula given
by Preston10

In North Americans
(Using Preston
proportion10)

In Nepalese
(Using NED
proportion)

CIW

ICW
2[1+ LI/CI +
(LI/CI CN/LI)]

ICW
2[1+ 0.66 + (0.66
0.84)]

ICW
2[1+ 0.66 + (0.66
0.70)]

LIW

CIW LI/CI

CIW 0.66

CIW 0.66

LIW CN/LI

LIW 0.84

LIW 0.70

CNW

NED: Nepalese Esthetic Dental; CIW: central incisor width; LIW: lateral incisor width; CNW: canine width; ICW: intercanine width of six maxillary teeth;
CIL: central incisor length; LIL: lateral incisor length; CNL: canine length; CI:
central incisor; LI: lateral incisor; CN: canine.

Among North Americans, various teeth proportions have


been proposed for the restoration of anterior teeth.10,14 A
study by Preston of 58 computer generated images of dental
casts of a North American population found that only 17%
of the lateral incisors were in GP with the central incisors.10
He suggested that the optimal LI/CI should be 66% instead
of 62% and CN/LI should be 84%. Thus, he proposed these
values as the Preston Proportion. Ward suggested that the
ratio between two adjacent teeth should remain constant
as progressing distally when observed in a frontal view.14
He found that when the 62% was used, the lateral incisor
appeared too narrow and the resulting canine was not
prevalent enough. Therefore, he proposed the Recurrent
Esthetic Dental (RED) proportion ranging from 60% to 80%.
He preferred using the 70% proportion for LI/CI and CN/
LI. In addition, Preston proposed the formula for maxillary
anterior teeth width calculation in North Americans using
the Preston proportion (Table 3).10 Similarly, Ward also
proposed the formula for maxillary anterior teeth length
calculation in North Americans using the RED proportion
(Table 4).14 Another study by Calcada et al. in a Portuguese
population (50 dental patients) found that the proportions
between the widths of the maxillary anterior teeth
exhibited the Preston proportion of 66% rather than the GP
and the RED proportions.30 A study by Murthy and Ramani
in an Indian population evaluated the existence of GP and
RED proportion in natural dentition discovering that GP
and RED proportions were not seen in natural dentition.24
Regarding teeth proportion in the total Nepalese
population, a combination of the Preston and RED
proportions was found in our study. The mean LI/CI in the
total population was 66%, similar to the Preston proportion,
while the mean CN/LI was 70%, similar to the 70% RED
proportion.10,14 The CIL/2CIW in total studied population

Original Article

VOL. 13 | NO. 3 | ISSUE 51 | JULY-SEPT. 2015

Table 4. Formula proposed by Ward14 to calculate maxillary


anterior teeth length and application in Nepalese population
Anterior
teeth
length

Formula
given by
Ward14

Maxillary anterior teeth length calculation


In North Americans
(Using RED
proportion14)

In Nepalese
(Using NED
proportion)

CIL

CIW
CI WLRs

CIW
0.70

CIW
0.90

LIL

LIW
LI WLRs

LIW
0.70

LIW
0.86

CNL

CNW
CN WLRs

CNW
0.70

CNW
0.89

NED: Nepalese Esthetic Dental; CIW: central incisor width; LIW: lateral
incisor width; CNW: canine width; ICW: intercanine width of six maxillary teeth; CIL: central incisor length; LIL: lateral incisor length; CNL:
canine length; CI: central incisor; LI: lateral incisor; CN: canine; WLRs:
width to length ratios.

was 55%.The WLRs in total studied population were found


about 90% for central incisors, 86% for lateral incisors
and 89% for canines. Therefore, we propose these values
as the Nepalese Esthetic Dental (NED) proportion and it
might be used for maxillary anterior teeth size estimation
in Nepalese. For teeth width calculation, if the width of
the CI is x, then the width of the LI should be 66% of x,
which is 0.66x, and the width of CN should be 70% of 0.66x,
which is 0.46x (Fig. 4). Furthermore, teeth width and length
in Nepalese patients can be calculated by the formulae
given by Preston10 and Ward14 using NED proportion
obtained from this study (Tables 3, 4). This can be used
in edentulous, partial edentulous and dentulous patients
with loss of tooth structure (attrition, abrasion, erosion
or trauma) in maxillary anterior region. In addition, teeth
size calculation using the NED proportion might be helpful
not only in clinical practice but also in the manufacture of
artificial teeth moulds.

CONCLUSION
No significant differences were found in teeth proportions
of maxillary anterior teeth among three facial types. Teeth

Figure 4. Teeth proportions in total population and the Nepalese


Esthetic Dental (NED) proportion. LI/CI, perceived width ratios
of lateral incisor to central incisor; CN/LI, perceived width ratios
of canine to lateral incisor; CIL/2CIW, ratios of mean central
incisor length to 2 central incisor widths; CI, central incisor; LI,
lateral incisor; CN, canine; WLR, width to length ratio.

proportions in the total studied population significantly


differed from GP and GS. Hence, GP and GS may not be
applicable for maxillary anterior teeth proportions in the
Nepalese population. In the total studied population, the
mean LI/CI was 66%, the mean CN/LI was 70% and the
mean CIL/2CIW was 0.55. The WLRs were found to be 90%
for central incisors, 86% for lateral incisors and 89% for
canines. We propose these values as the Nepalese Esthetic
Dental (NED) proportion which may serve as a guideline
for treatment planning, restorative dental treatment and
esthetic smile design in the maxillary anterior region in the
Nepalese population.

ACKNOWLEDGEMENT
The authors thank Associate Professor Nita Viwattanatipa
and Dr. Pokpong Amornvit, Faculty of Dentistry, Mahidol
University for their guidance, Assistant Professor Chulaluk
Komoltri for the tremendous assistance in the statistical
analysis, and Dhulikhel Hospital, Kathmandu University
School of Medical Sciences for the support in the conduct
of this research.

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